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Cardiovascular
SystemNormal
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ANATOMYAND
PHYSIOLOGY
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Heart and Heart Wall Layers Located in the left side of the
mediastinum Consists of 3 Layers:
EPIcardium MYOcardium
ENDOcardiumEPI-MYO-ENDO
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Pericardial Sac Encases and protects the heart from
trauma and infectionHas 2 Layers:
Parietal Pericardium Tough, fibrous outer membrane
Visceral Pericardium Thin, inner layer that closely adheresto the heart
Pericardial Space Between PP and VP; holds 5-20 ml of
pericardial fluid Lubricates pericardial surfaces and
cushions the heart
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Structures ofthe Heart
ChambersAtria- (2) upper chambers
Thin walledReceive blood from veins
Send blood to ventriclesVentricles- (2) lower
chambersThick walled
Receive blood from atriaPump blood out througharteries
SeptumWall that divides heart
into right and lefthalves
Septum
Pulmonary valve
Right atrium
Tricuspid valve
Right ventricle
Left atrium
Aortic valve
Mitral valve
Left ventricle
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Prevent backflow of bloodKeep blood moving in one
direction
Between the chambersAt junctions of artery
and chamber
Tricuspid valve
Pulmonary veins
Mitral valve
Left atrium
Pulmonary valve
Aortic valve
Right atrium
Valves seen from above
Chordea tendinea
Pulmonaryvalve
Valves
http://www.delftoutlook.tudelft.nl/info/fullimage252b.html?ImageID=4075http://www.delftoutlook.tudelft.nl/info/fullimage252b.html?ImageID=4075http://www.delftoutlook.tudelft.nl/info/fullimage252b.html?ImageID=4075http://www.delftoutlook.tudelft.nl/info/fullimage252b.html?ImageID=4075http://www.delftoutlook.tudelft.nl/info/fullimage252b.html?ImageID=40757/31/2019 Cardiovascular System - Normal
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Chordae
tendinease Heart strings Cord-like
tendons
Connect papillarymuscles totricuspid andmitral valves
Prevent inversionof valve
Papillary muscles Small muscles
that anchor the
cords
Papillarymuscle
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aortic valve
left common carotid artery
left subclavian artery
brachiocephalic artery
right pulmonary artery
septum
left pulmonary artery
aorta
pulmonary trunk
left pulmonary veins
left atrium (auricle)
mitral valve
pulmonary valve
papillary muscle
left ventricle
right pulmonary veins
superior vena cava
right atrium
tricuspid valve
right ventricle
inferior vena cava
2006 Merriam-Webster, Inc.
Structures of the Heart
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Chambers of the Heart
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Great Vessels of theHeart
Superior and InferiorVena Cava
Pulmonary Arteries Pulmonary VeinsAorta
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ATRIOVENTRICULARVALVES
Close at the beginning ofventricular contraction
Prevents blood from flowing backin the atria from the ventricles
Open when the ventricle relaxes Tricuspid Valve right side of the
heart Bicuspid (mitral) Valve left side
of the heart
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SEMILUNAR VALVES
Prevents blood from flowing backinto the ventricles duringrelaxation
Open during ventricularcontraction
Close when ventricles begin torelax
Pulmonic Semilunar Valve Lies between RV and PA
Aortic Semilunar Valve Lies between LV and Aorta
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Bl d l
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Blood Flowthrough the
HeartSVC &IVC
Right Atrium
Tricuspid Valve
Right Ventricle
Pulmonary SemilunarValve
Pulmonary Arteries
L
U
N
G
S
Pulmonary Veins
Left Atrium
Bicuspid / Mitral Valve
Left Ventricle
Aortic Semilunar Valve
Aorta
BODY
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Conduction System
Generates and transmitselectrical impulses that
stimulate contraction ofthe myocardium
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Conduction System Sinoatrial Node (SA Node)
Main pacemaker that initiates eachheartbeat
Located at the junction of SVC andRA
Generates electrical impulses at 60-
100 times per minute Controlled by the sympathetic andparasympathetic nervous system
Atrioventricular Node (AV Node) Located in the lower aspect of the
atrial septum Receives electrical impulses from SA
node If SA node fails, AV node can initiate
40-60 bpm
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Bundle of His Continuation of the AV node
Right and Left bundle branches
Purkinje Fibers Diffuse network of conducting
strands located beneath theventricular endocardium
Spread the wave of depolarization
through the ventricles Can act as a pacemaker at 20-40bpm when higher pacemaker fail
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Coronary Arteries Supply the capillaries of myocardium
with blood Right coronary artery
Supplies the RA and RV, inferiorportion of the LV, posterior septal
wall, SA and AV nodes Left coronary artery Left anterior descending artery
Supplies blood to the anteriorwall of the LV and apex of theLV
Circumflex artery Supplies blood to the left atriumand the lateral and posterior
surfaces of the LV
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Heart Sounds S1
1stheart sound Heard as the AV valves close
Heard loudest at the apex of theheart
S2 2nd heart sound Heard when SL valves close Heard loudest at the base of the heart
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Listen to heart with stethoscope: lubb-dupp
lubb: start of ventricular contraction
dupp: start of ventricular relaxation
Ab l H t
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Abnormal HeartSounds
Paradoxical SplittingAbnormal splitting of S2 Caused by early closure ofpulmonic valve or delay inaortic valve closure
Gallops S3 and S4
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S3 (Ventricular Gallop) Heard if ventricular wall compliance is
decreased and structures in the
ventricular wall vibrate CHF, valvular regurgitation Normal in individuals younger than 30
years old
S4 (Atrial Gallop)Abnormal finding Resistance to ventricular filling Cardiac hypertrophy
Disease Injury to the ventricular wall Quadruple Gallop
Severe heart failure
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Murmurs Reflect turbulent blood flow
through normal or abnormalvalves Systolic murmurs
Occur between S1 and S2 Diastolic murmurs
Occur between S2 and S1 Pericardial Friction Rub
Sign of inflammation orinfection
Pericarditis, cardiac tamponade
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Cardiac Output Volume of blood in litersejected by the heart
each minute 4 7 liters/minute Cardiac Output = Heart
rate/ Stroke volume
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Heart Rate The FASTER the HR, the less time the
heart has for filling and the cardiacoutput decreases
Increase in HR = increase in oxygenconsumption
Normal HR: 60-100 bpm
Sinus Tachycardia: more than 100bpm Sinus Bradycardia: less than 60 bpm
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Stroke VolumeAmount of bloodejected by the left
ventricle during eachsystole
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Preload Degree of myocardial fiber
stretch at the end ofdiastole and just before
contraction Determined by the amount
of blood returning to the
heart from both the rightheart and left heart
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Afterload Pressure or resistance thatthe ventricles must
overcome to eject blood
through the semilunarvalves and into theperipheral blood vessels
Amount of resistance isdirectly related to arterialblood pressure and thediameter of blood vessels
A t i N
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Autonomic NervousSystem
Sympathetic Response Release of norepinephrine
increase HR and peripheralvasoconstriction
Stimulation occurs when decreasein BP is detected
Parasympathetic Response Release of acteylcholine
decreases HR Stimulation occurs when
increasein BP is detected
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BP Control When BP decreases as a result ofhypovolemia, sympathetic response occurs =
increase HR and BP When BP increases as a result of
hypervolemia, parasympathetic responseoccurs = decrease HR and BP Antidiuretic hormone (vasopressin) influences
BP by regulating vascular volume
Increase in blood volume = decrease ADH= increase in diuresis (ihi) = decrease BP Decrease in blood volume = increase ADH
= decrease in diuresis (ihi) = increase BP
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Renin, a vasoconstrictor, causesBP to increase
Renin converts angiotensin toangiotensin I; angiotensin I isthen converted to angiotensin IIin the lungs
Angiotensin II stimulates releaseof aldosterone, which promotessodium and water retention by
the kidneys, thus, increaseblood volume and BP
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Vascular System Arteries
Blood passes AWAY from the heart Convey highly oxygenated blood
Veins
Carry deoxygenated blood TO theheart
CapillariesAllow exchange of fluid and nutrients
between blood and interstitial spaces Lymphatics
Drain the tissues and return tissuefluid to the blood
Blood vessels have different structures:
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Blood vessels have different structures:Arteries and Arterioles
Epithelial cells of arteries/veins are surrounded by smooth muscle andconnective tissue Arteriesare very elastic (a property of connective tissue), to
accommodate very high blood pressure leaving the heart Arterioles are less elastic and have more smooth muscle, allowing
constriction/dilation
Blood vessels have different structures:
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Blood vessels have different structures:Veins
Veins have thinner walls and less musclethan arteries (lower blood pressure) Valves in veins prevent the backflow of
blood Blood flow is aided by muscular
contractions
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Types of
Circulation
di l
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Pulmonary Circuit
Systemic Circuit
Lung
Pulmonary
vein
Aorta
Left
atrium
Left
ventricle
Pulmonary
artery
Right
atrium
Right
ventricle
Vena
cava
oxygen-poor blood
oxygen-rich blood
CardiovascularCircuits
P l a
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PulmonaryCirculation
Takes place on theright side of theheart.
Pumps blood low inoxygen to the lungsto pick up oxygen andreturn to heart
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Coronary Circulation
Although blood fills the
chambers of the heart,the muscle tissue ofthe heart is so thick thatit requires coronary bloodvessels to deliver blood
deep into themyocardium.
The coronary circulation consists of the blood vessels
that supply blood to, and remove blood from theheart muscle itself.
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Coronary Circulation
The vessels that supply blood high in oxygen tothe myocardium are known as coronaryarteries.
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Hepatic Portal System
H p ti P t l S st
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Hepatic Portal SystemThe liver is the only digestive organdrained by the inferior vena cava- blood leaving the capillary bedssupplied by the celiac and superior andinferior mesenteric arteries flows intothe veins of the hepatic portal system
- a blood vessel connecting 2 capillarybeds is a portal vessel and the networkis a portal system
Venous blood that absorbs nutrientsfrom the small intestine, parts of thelarge intestine, stomach, and pancreasflows directly to the liver- regulates levels of nutrients and
amino acids in the circulating blood
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Fetal Circulation
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Fetal Circulation
O t d bl d t th bili l i f th l t
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Oxygenated blood enters the umbilical vein from the placenta
Enters ductus venosus
Passes through inferior venacavaEnters the right atrium
Enters the foramen ovale
Goes to the left atrium
Passes through left ventricle
Flows to ascending aorta to supply nourishment tothe brain and upper extremeties
Enterssuperiorvena cava
Goes to right atrium
Enters the right ventricle
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Enters pulmonary artery withsome blood going to the lungs
to supply oxygen andnourishment
Flows to ductus arteriosus
Enters descending aorta ( someblood going to the lower
extremeties)
Enters hypogastric arteries
Goes back to the placenta
S i l St t i F t l
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Special Structures in FetalCirculation
Placenta Where gas exchange takes placeduring fetal life
Umbilical Arteries Carry unoxygenatedblood from the fetus to placenta
Umbilical Vein Brings oxygenated bloodcoming from the placenta to the fetus
Foramen Ovale Connects the left and rightatrium. It pushes blood from the right atrium
to the left atrium so that blood can besupplied to brain, heart and kidney
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Ductus Venosus - Carry oxygenatedblood from umbilical vein to inferiorvenacava, bypassing fetal liver
Ductus Arteriosus - Carry
oxygenated blood from pulmonaryartery to aorta, bypassing fetallungs.
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DiagnosticTests and
Procedures
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Cardiac Enzymes
CK-MB (Creatine kinase,myocardial muscle) Reflects cell trauma Elevation indicates myocardial damage
Elevation occurs within 4-6 hours andpeaks 18-24 hours following an acuteischemic attack
Normal value is 0-5% of the total Total CK is 26-174 units/L Isoenzymes
CK MB Cardiac muscle CK MM Skeletal muscle CK BB Brain tissue
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Cardiac Enzymes
Lactate dehydrogenase(LDH) Elevation occurs 24 hours
following MI and peak in 48-72hours Normally LDH 1 is lower than
LDH 2. if opposite, the pattern is
flipped indicating myocardialnecrosis Normal: 140-280 IU/L
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Cardiac Enzymes
Troponin Composed of 3 proteins: Troponin C Cardiac Troponin I Cardiac Troponin T
Trop I: lower than 0.6 ng/mL Rises within 3 hours and persists
for up to 7 days Higher than 1.5 ng/mL consistent
with MI Trop T: 0-0.2 ng/mL Any rise indicate myocardial cell
damage Commonly used in the Philippine
setting to detect MI
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Cardiac Enzymes
Myoglobin Oxygen binding protein found in
cardiac and skeletal muscle
Level rises within 1 hour after celldeath, peaks in 4-6 hours andreturns to normal within 24-36hours
Normal: lower than 90 mcg/L Elevation could indicate MI
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Other Normal Values
Creatine kinase CK Male 55-170U/L Female 30-135 U/L
CK - MB (isoenzyme) 0-7 U/L Lactic dehydrogenase (LDH)
LDH1 22%-36%
LDH2 35%-46% LDH313%-26% LDH4 3%-10%
LDH52%-9%
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Complete Blood Count
RBC decreases in RHD and endocarditis;and increases in conditions withinadequate tissue oxxygenation
WBC increases in infectious andinflammatory diseases of the heart andafter MI
Elevated hematocrit level can resultfrom vascular volume depletion(hypovolemia)
Decrease in Hemoglobin (hgb) andHematocrit (hct) can indicate anemia
Red blood cell countilli
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Men 4.7-6.1 million/mm3 Women 4.2-5.4 million/mm3 Infants and children 3.8-5.5 million/mm3 Newborns 4.8-7.1 million/mm3
White blood cell count Adults and children greater than two years of age
5,000-10,000/cm3 Children less than two years 6,200-17,000/mm3 Newborns 9000-30,000/mm3
Hematocrit Men 42-52% Women 37-47% (pregnancy>33%) Children 31-43% Infants 30-40% Newborns 44-64%
Hemoglobin Men 13.5-18.0 g/dl Women 12-16 g/dl (pregnancy >11 g/dl) Children 11-16 g/dl Infants 10-15 g/dl Newborns 14-24 g/dl
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Coagulation Studies
An increase in coagulationfactors can occur during andafter MI which places the client
at risk for thrombophlebitis andextension of clots in thecoronary arteries aPTT
PT Clotting time Platelet count
A i d P i l h b l i
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Activated Partial ThromboplastinTime (aPTT)
Measures the amount of time it takesin seconds for recalcified citratedplasma to clot after partialthrmboplastin is added to it
Used to monitor heparin therapy andscreen for coagulation studies
Normal: 20-36 seconds If value is prolonged, initiate bleeding
precautions
P th bi ti (PT)
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Prothrombin time (PT) Prothrombin is a vitamin K-dependent
protein produced by the liver necessary
for clot formation Measures the amount of time it takes in
seconds for clot formation Monitor warfarin therapy, vitamin K
deficiency, DIC Normal: PT value within 2 seconds of the
control (plus or minus) PT 9.6 11.8 seconds MALE PT 9.5 11.3 seconds FEMALE
Diet high in green leafy vegetablescan increase vitamin K, whichshortens the PT
PT longer than 30 seconds: bleedingprecaution
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Clotting time Time required for the
interaction of all factors
involved in the clottingprocess Normal: 8-15 minutes
Platelet count Normal: 150,000
400,000 cells/ mm If lower: bleeding precaution
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Lipid Assessment
Total cholesterol: less than 200mg/dL
Triglycerides: less than 200 mg/dL high density lipoprotein (HDL): 30-
70 mg/dL Good cholesterol
low density lipoprotein (LDL): lessthan 130 mg/dL
Elevated lipid assessment increasesthe risk of coronary artery disease
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Copyright 2005 Dr. Salme
Taagepera, All rights reserved.
http://images.medscape.com/pi/editorial/cmecircle/2004/3598/images/libby/slide005.gif
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Bad v. Good cholesterol!
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Electrolytes
Sodium 135-145 mEq/L
Potassium 3.5 5 mEq/L
Calcium 8.6 10 mg/dL or 4 5 mEq/L
Magnesium
1.6 2.6 mg/dL Phosphorus
2.7 4.5 mg/dL
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Potassium Hypokalemia: cardiac
instability, dysrhythmias
T wave inversion, U wave,ST depression Hyperkalemia: ventricular
dysrhythmias Tall peaked T waves,prolonged PR intervals, flatP waves
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Sodium Decreases with the use of diuretics Increases in heart failure,
indicating water excess
Calcium Hypocalcemia: ventricular
dysrhythmias, cardiac arrest Hypercalcemia: AV block,
tachy/bradycardia, cardiac arrest
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Phosphorus Should be interpreted with calcium
levels because kidneys retain or excreteone electrolyte in an inverse relationship
Magnesium Low: ventricular tachycardia and
fibrillation; tall T waves, depressed STsegments
High: muscle weakness, hypotension andbradycardia, prolonged PR, widenedQRS
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Blood Urea Nitrogen Elevated in heart disorders that
adversely affect renal circulation suchas heart failure and cardiogenic shock
Normal: 8-25 mg/dL Blood Glucose
Elevated in acute cardiac episodes Normal FBS: 70-110 mg/dL
B-type natriuretic peptide
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B type natriuretic peptide(BNP)
Released in response toventricular and atrial stretch
Marker for CHF
Normal: should be lower than100 pg/mL The higher the level, the more
severe CHF is
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Chest X-ray
Done to determine the size,silhouette and position ofthe heart
Remove jewelry
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Echocardiography (ECG)
Noninvasive test that records the electricalactivity of the heart
Useful for detecting cardiac dysrhythmias,location and extent of MI and evaluationof cardiac medications
Client should lie still, breathe normally No electrical shock can occur
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Holter Monitoring
ECG tracing over a period of 24hours or more as the client performsADLs
Client wears a Holter monitor
Avoid tub baths and showering
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Echocardiography
Noninvasive Based on the principle of ultrasound Evaluates structural and functional
changes of the heart
Client should lie still and breathenormally
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Exercise testing (Stress test)
Studies the heart during activity andevaluates coronary artery disease
Treadmill testing is the mostcommonly used
If the client is unable to tolerateexercise, IV infusion of dipyridamole(Persantine), dobutamine oradenosine is given to dilate the
coronary arteries Can be invasive if used withradionuclide testing
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Client Education
Adequate rest night before procedure Eat a light meal 1-2 hours Avoid smoking, alcohol and caffeine Meds withheld prior the procedure:
Theophylline 12 hours Beta blockers and calcium channel
blockers 24 hrs
POST: Avoid hot bath 1-2 hoursafter
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Digital Subtraction
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Digital SubtractionAngiography
Combine x ray with fluoroscopy forvisualization of the cardiovascularsystem
Contrast medium (dye) is injected
Assess allergies to seafood, iodine Pre-medicate with antihistamine
and steroids to avoid untowardreactions
POST Monitor VS and injection site for
bleeding
Magnetic Resonance Imaging
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Magnetic Resonance Imaging
(MRI)
Produces images of the heartand great vessels throughinteraction of magnetic fields
Provides info on chamber size,
thickness, valves and blood flowthrough great vessels andcoronary arteries
CONTRA:
Pacemaker and otherimplanted items
Metallic objects Claustrophobia
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Cardiac Catheterization
Invasive test involving insertion of acatheter into the heart andsurrounding vessels
Femoral vein: entry point
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PRE Consent
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Consent Assess allergies to dye
Seafood, iodine Withhold solid food 6-8 hours and liquid 4
hours to prevent vomiting and aspiration Document clients height and weight
Baseline VS and peripheral pulses Local anesthetic before catheter insertion Need to lie still on a hard table for 2 hours Client may feel a warm, flushed sensation, a
desire to cough and palpitations as the dye isinjected
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Prepare the insertion site by shavingand cleaning with antiseptic solution
Insert IV line as prescribed Withhold Metformin 48hrs prior
POST
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Monitor VS and cardiac rhythm at leastevery 30 minutes for 2 hours initially
If chest pain occurs, notify the physician Monitor extremity of insertion site at least
every 30 minutes for 2 hours Peripheral pulses
Color Warmth Sensation
Notify physician Extremity is cool, pale, cyanotic, loss ofperipheral pulse, hematoma
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Keep the leg (insertion site)extended and straight 4-6 hours
to prevent arterial occlusion Strict bed rest 6-12 hours; may
turn side to side Encourage fluid intake to promote
renal excretion of dye
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C t l V P
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Central Venous Pressure
CVP: pressure under which blood isreturned to the SVC and RA
Normal CVP: 3-8 mmHg Elevated: increase in blood volume
due to sodium and water retention,renal failure, excess IV fluids
Decreased: hypovolemia, hemorrhage,severe vasodilation with blood pooling
in the extremities
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Client should be in supine, HOB 45degreesActivity increases intrathoracic
pressure (false high result)
Zero point of the transducershould be at the level of the rightatrium Midaxillary line at the 4th
intercostal space
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Therapeutic
Management
Percutaneous TransluminalCoronary Angioplasty (PTCA)
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Coronary Angioplasty (PTCA)
Invasive, nonsurgical technique One or more arteries are dilated
with a balloon catheter to openthe vessel lumen and improve
arterial blood flow Client can experience re-occlusion
after the procedure Complications:
Arterial rupture Immobilization of plaque Spasm
MI
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PRE
NPO post midnight Informed consent, allergy
assessment, hold metformin Prepare the groin area with
antiseptic soap and shave Assess VS and peripheral pulses Instruct client to report chest pain
during balloon inflation
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POST
Monitor VS, pulses Keep the leg (insertion site) extended
and straight 6-8 hours Bed rest
Administer anticoagulants (heparin)to prevent thrombus formation
Increase OFI to excrete dye
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Percutaneous coronary interventionstenting.flv
3D stent animation
A gioplasty
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Angioplasty
Laser probe is inserted to theaffected artery
Heat from the laser vaporizes theplaque
Similar care as PTCA
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Coronary Artery Stents
Used in conjunction with PTCA To provide a supportive scaffold to
eliminate the risk of acute coronaryvessel closure and to improve long term
patency of the vessel Balloon catheter bearing the stent isinserted into the coronary artery andpositioned at the site of occlusion
Balloon inflation deploys the stent When placed in the coronary artery,stent reopens the blocked artery
d
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PRE and POST
Similar with PTCA Client is placed on antiplatelet
therapy for several months after theprocedure because of acute
thrombosis Clopidogrel (Plavix)Aspirin
Bleeding precaution
Atherectomy
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Atherectomy
Removes plaque from a coronaryartery by the use of a cuttingchamber on the inserted catheter ora rotating blade that pulverizes the
plaque Used to improve blood flow toischemic limbs in individuals withperipheral arterial disease
Care similar to PTCA
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Coronary Artery BypassG f
7/31/2019 Cardiovascular System - Normal
112/115
Graft
Occluded arteries are bypassed withclients own blood vessels
Saphenous veins, internal mammaryartery may be used to bypass
Performed when client does notrespond to medical management orwhen vessels are severely occluded
7/31/2019 Cardiovascular System - Normal
113/115
7/31/2019 Cardiovascular System - Normal
114/115
Heart bypass.flv Beating heart surgery.flv
7/31/2019 Cardiovascular System - Normal
115/115
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